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The Open University will take its first batch of students next January. In this article Dr Stannard discusses the thinking that has gone into the foundation course in science, and outlines some of the problems involved in adapting teaching techniques to make the best use of television, radio and correspondence courses.
Engineered biological systems have been used to manipulate information, construct materials, process chemicals, produce energy, provide food, and help maintain or enhance human health and our environment. Unfortunately, our ability to quickly and reliably engineer biological systems that behave as expected remains quite limited. Foundational technologies that make routine the engineering of biology are needed. Vibrant, open research communities and strategic leadership are necessary to ensure that the development and application of biological technologies remains overwhelmingly constructive.
A recent report on diet and oral health by the British Nutrition Foundation reviews the anatomy, microbiology and pathology of a number of oral diseases including dental caries, tooth-wear, oral cancer, periodontal disease and enamel defects. The role of nutritional factors in the aetiology and prevention of these oral diseases is discussed. The report states that improvements in the levels of caries in the UK are halting and remain unacceptably high in some 'at risk groups'--including the socially deprived. It states that a two-pronged attack, i.e. reduced frequency of consumption of sugary foods and use of fluoride is necessary to address the problem. To address the increased prevalence of oral cancer avoiding tobacco, limiting alcohol and increasing fruit and vegetable consumption are recommended. Recommendations for approaches to improve oral health are made for health authorities, industry, schools and health professionals and it is recommended that the Government make adequate resources available to improve oral health preventive strategies.
Understanding the local and regional patterns of species distributions has been a major goal of ecological and evolutionary research. The notion that these patterns can be understood through simple quantitative rules is attractive, but while numerous scaling laws exist (e.g., metabolic, fractals), we are aware of no studies that have placed individual traits and community structure together within a genetics based scaling framework. We document the potential for a genetic basis to the scaling of ecological communities, largely based upon our long-term studies of poplars (Populus spp.). The genetic structure and diversity of these foundation species affects riparian ecosystems and determines a much larger community of dependent organisms. Three examples illustrate these ideas. First, there is a strong genetic basis to phytochemistry and tree architecture (both above- and belowground), which can affect diverse organisms and ecosystem processes. Second, empirical studies in the wild show that the local patterns of genetics based community structure scale up to western North America. At multiple spatial scales the arthropod community phenotype is related to the genetic distance among plants that these arthropods depend upon for survival. Third, we suggest that the familiar species-area curve, in which species richness is a function of area, is also a function of genetic diversity. We find that arthropod species richness is closely correlated with the genetic marker diversity and trait variance suggesting a genetic component to these curves. Finally, we discuss how genetic variation can interact with environmental variation to affect community attributes across geographic scales along with conservation implications.
PURPOSE: Patients with priapism often develop permanent erectile dysfunction and personal sexual distress. This report is intended to help educate the public by reviewing the varied definitions and classifications of priapism and limited literature reports of pathophysiology, diagnosis and treatment outcomes of priapism. The AUA priapism guidelines committee is responsible for creating consensus as to appropriate individual patient management of priapism by physicians. MATERIALS AND METHODS: A multidisciplinary panel, consisting of 19 thought leaders in priapism, was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease to address pertinent issues concerning the role of the urologist, primary care providers and other health care professionals in the education of the public regarding management of men with priapism. The panel utilized a modified Delphi method and built upon the peer review literature on priapism. RESULTS: The Thought Leader Panel recommended adoption of the definition of priapism as a pathological condition of a penile erection that persists beyond or is unrelated to sexual stimulation. Priapism is stressed to be an important medical condition that requires evaluation and may require emergency management. The classification system is categorized into ischemic and non-ischemic priapism. Essential elements of the ischemic classification are the inclusion of: (i) clinical characteristics of pain and rigidity; (ii) diagnostic characteristics of absence of cavernosal arterial blood flow; (iii) pathophysiological characteristics of a closed compartment syndrome; (iv) a time limit of 4 h prior to emergent medical care; and (v) a description of the potential consequences of delayed treatment. Essential elements of the non-ischemic classification are the inclusion of: (i) clinical characteristics of absence of pain and presence of partial rigidity; (ii) diagnostic and pathophysiological characteristics of unregulated cavernosal arterial inflow; and (iii) the need for evaluation but emphasizing the lack of a medical emergency. The panel recommended adoption of a rational management algorithm for the assessment and treatment of priapism where the cornerstone of initial assessment includes a careful clinical history, a focused physical examination and selected laboratory and/or radiologic tests. The panel recommended that specific criteria and clinical profiles requiring specialist referral should be identified. The panel further recommended that patient (and partner) needs and education concerning priapism should be addressed prior to therapeutic intervention, however only in the case of chronic management or post acute presentation evaluation should this delay intervention. Treatment goals to be discussed include management of the priapism with concomitant prevention of permanent and irreversible erectile dysfunction and associated psychosocial consequences. The panel recommended that when specific therapies for priapism are required, a step-care treatment approach based upon reversibility and invasiveness should be followed. CONCLUSIONS: The Thought Leader Panel calls for research to expand our understanding of the prevalence and diagnosis of priapism and education to create awareness among the public of the potential urgency of this condition. Critical areas to be addressed include the multiple pathophysiologies of priapism as well as multi-institutional trials to objectively assess safety and efficacy in the various treatment modalities.
The International Foundation of Dermatology (IFD) was established by the International League of Dermatology Societies to promote the care of skin disease in the developing world. Starting from an initial base of the Regional Dermatology Training Centre in Tanzania it has successfully trained a cadre of clinical officers and dermatology residents from different African countries. It has now broadened this approach to an assessment of the effectiveness of focused training in Mali. The IFD is also completing a global assessment of dermatological needs in developing countries with a view to establishing guidelines and programmes for the control of common skin diseases. An ongoing strategy has been to work with other agencies to help ease the burden of other endemic tropical diseases that affect the skin; preventing the development of elephantiasis in filarial lymphoedema has been one such project implemented through a programme of skin hygiene.
Until the late 1980s community care was traditionally the preserve of the health and social care agencies that dominated the planning and provision of care. Since then it has increasingly been recognized that housing should also play a major role in community care. This has been apparent in official guidance and statements, in some of the more innovative forms of community care provision, and in some of the academic literature. Yet the advancement of the housing dimension of community care in the 1980s has arguably become as much of a bland truism as the idea of community care itself has always been. What has remained largely absent from the debate is a considered and critical view of the meaning and potential role of housing in community care, or - more specifically - an agreed vision of the benefits a housing orientation can bring to the quality of community care. This article draws together many strands of the argument. It critically examines the emergence and development of the idea of housing as a 'key' component - even the 'foundation' - of community care, identifying some of the reasons why the housing dimension has risen from a seriously marginalized position to the central role which it is now often suggested it should occupy. The authors conclude by arguing that, whilst some progress has been made, a fundamental shift in thinking is still required at many levels. They suggest that community care users have consistently claimed that housing is the first essential component of effective community care. What is needed is for other participants in the community care process to endorse and develop an ordinary housing approach to community care, in which housing is genuinely accepted as the vital component and which can be translated into practice. This fuller recognition of the housing contribution must embrace meanings which can be agreed, understood and operationalized by the main participants in community care.
The subject of biology was identified as a cause of anxiety amongst student nurses on the common foundation programme (CFP), both verbally and in each of the written course evaluations, at a college of nursing and midwifery in the South of England. The aim of this study was to identify the major causes of anxiety and identify methods of reducing this anxiety in the present students, as well as minimizing anxiety in those students commencing their nurse education. Action research was considered the most appropriate design for this study. Student nurse participation was encouraged throughout the study (n = 66). A modified Delphi technique was used to identify and prioritize the causes of anxiety and a student quality circles group was formed for the purpose of problem solving by the students. This stimulated some of the biology teachers to form biology sub-groups to consider the students' proposals. Many changes were implemented. A focus group data collection method was used to evaluate the effectiveness of the relevant changes for the present students. The meeting was recorded and the tape examined for relevant data. The data indicated that although the students perceive biology as a subject that causes anxiety they did acknowledge that many of the changes made by the teachers were a positive step towards reducing the anxiety. Although the results were encouraging, it is noted that to gain a true understanding of the effect of the changes, further evaluation would need to be completed. The use of triangulation may be considered more appropriate to enhance the quality of the data obtained.
The study reported in this paper investigated the mentoring experiences and perceptions of pre-registration nursing students in one organization, on a theory/practice nursing module. It considered the extent to which students' understanding and expectations matched their actual experiences. Interviews were conducted with 35 students on a Common Foundation Programme, and 15 allocated mentors, using a semi-structured interview guide. These were done within the clinical setting of the wards on which the students were placed as part of their requirements for completion of the module. A distortion of the actual meaning of mentoring appears to be present because of the lack of clarity provided, both internally by organizations and by the English National Board (ENB) who have provided loose guidelines. The implications of this distortion are discussed. The application of a mentoring role in practice needs to be re-examined, with the provision of a clear structured guide internally and externally, with regard to the needs of students and staff who are expected to act as mentors. The study was small scale and cannot be generalized. Mentoring, however, is now widely used within pre-registration nursing education, even though it is generally considered that its use may not be appropriate. Follow-up studies need to be undertaken on an ongoing basis, to examine what actually happens in practice, and to consider ways of ensuring that the benefits for staff and students are enhanced.
The scientific foundations of conservation policy are the subject of a recent tripolar debate, with systematists arguing for the primacy of phylogenetic rankings, ecologists arguing for protection at the level of populations or ecosystems, and evolutionary biologists urging more attention for the factors that enhance adaptation and biodiversity. In the field of conservation genetics, this controversy is manifested in the diverse viewpoints of molecular systematists, population biologists, and evolutionary (and quantitative) geneticists. A resolution of these viewpoints is proposed here, based on the premise that preserving particular objects (genes, species, or ecosystems) is not the ultimate goal of conservation. In order to be successful, conservation efforts must preserve the processes of life. This task requires the identification and protection of diverse branches in the tree of life (phylogenetics), the maintenance of life-support systems for organisms (ecology), and the continued adaptation of organisms to changing environments (evolution). None of these objectives alone is sufficient to preserve the threads of life across time. Under this temporal perspective, molecular genetic technologies have applications in all three conservation agendas; DNA sequence comparisons serve the phylogenetic goals, population genetic markers serve the ecological goals, quantitative genetics and genome explorations serve the evolutionary goals.
In a study using unstructured interviews to explore nurses' understanding and interpretations of caring in nursing, one of the major themes emerging from the data is that through caring for patients, nurses discover the meaning and nature of nursing and what it means for them to be nurses. In the process of caring for patients, nurses further develop and understand the knowledge and skill of caring which constitutes the knowledge base of nursing. The data also show that nurses, in their practice, continue to define, develop and shape the meaning and knowledge of caring in nursing. From the evidence of this study, this paper argues that caring can be considered as the ontological and epistemological foundations of nursing.
This paper describes the foundations of community nursing in England, Ireland and New South Wales. It is guided by Foucault's work on power, discourse and knowledge, and argues that the common discourse of poverty coupled with the influence of socially advantaged women in the nineteenth century was the impetus for the development of community nursing in England, Ireland and New South Wales. Throughout the nineteenth century in Great Britain, economic and industrial development, coupled with an unprecedented growth in the population (particularly among the poor) inspired socially advantaged women to extend traditional gender-specific roles to address the needs of the poor. Protestant women in England advanced professional nursing as a career for women and in Ireland and New South Wales; Catholic women pioneered professional nursing, targeting the poor as the focus of their practice. These women used prevailing social conditions to enhance their life options within the limits prescribed by social norms.
OBJECTIVE: The objective of this report is to provide, in detail, the evidentiary requirements contained in Version 2.0 of the Academy of Managed Care Pharmacy's (AMCP's) Format for Formulary Submissions and to elaborate on several key issues regarding the use of the Format that users, potential users, and pharmaceutical manufacturers have raised since AMCP published the first version of the guidelines in October 2000. BACKGROUND: The AMCP published its Format for Formulary Submissions in October 2000. The AMCP leadership and its members were motivated to develop these guidelines by a growing need to ensure that any increased utilization of medications, biopharmaceuticals, and vaccine products was appropriate and that newer products would bring added clinical and economic value to covered populations. Since publication of the Format, it has garnered nationwide publicity and attracted considerable positive and negative attention. As adoption of the AMCP Format has spread, manufacturers have begun to standardize the framework within which they present population-specific data. Since publication of the AMCP Format, the AMCP and the Foundation for Managed Care Pharmacy (FMCP) have continuously sought input from pharmaceutical manufacturers and health-system pharmacists through various venues to improve and clarify the process. Version 2.0 is the first attempt to address user's comments and concerns. METHODS: The majority of the article text is taken directly from Version 2.0 of the AMCP Format for Formulary Submissions published by the AMCP in October 2002. CONCLUSION: The AMCP and the FMCP believe that the AMCP Format is a tool that will help health systems establish a record of commitment to rational decision making, thus gaining the confidence of patients, clinicians, and members. While providing manufacturers a vehicle for communicating the scientifically based value of their product to a health system, the required evidence to substantiate that value argument allows a pharmacy and therapeutics committee to determine the clinical benefits of a drug, verify any cost savings the drug may generate, and determine the overall cost consequences to their health system. The AMCP Format for Formulary Submissions is an essential tool to evaluate medications, but requires thoughtful consideration as it is used.
The National Kidney Foundation Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Renal Failure was recently published in the American Journal of Kidney Diseases. This publication provides 27 clinical practice guidelines for adults and 10 clinical practice guidelines for children. The adult guidelines focus primarily on patients undergoing maintenance dialysis therapy, although there are several clinical practice guidelines on nutritional issues for patients with advanced chronic renal failure (CRF) not undergoing dialysis therapy. The pediatric guidelines focus entirely on children undergoing maintenance dialysis treatment. The present article discusses a number of the more prominent clinical practice guidelines for the adults. Among these is the recommendation that the protein-energy nutritional status in these patients should be assessed by a panel of measures rather than by any single measure. Also, non-dialyzed patients with advanced CRF (ie, glomerular filtration rate <25 mL/min) and those undergoing maintenance hemodialysis or chronic peritoneal dialysis should be prescribed a dietary energy intake of 35 kcal/kg/day for patients who are <60 years of age and 30 kcal/kg for patients >/=60 years of age. Maintenance hemodialysis patients should be prescribed 1.2 g protein/kg/d; chronic peritoneal dialysis patients should be prescribed 1.2 to 1.3 g protein/kg/d. For non-dialyzed patients with CRF (glomerular filtration rate <25 mL/min), 0.60 g protein/kg/d should be prescribed. For patients who will not accept such a diet or are unable to maintain an adequate energy intake on that diet, a protein intake of up to 0.75 g protein/kg/d may be prescribed. At least 50% of the protein intake for all of these patients should be of high biologic value. A guideline concerning indications for inaugurating maintenance dialysis treatment or renal transplantation on the basis of deteriorating nutritional status is also given.
Since 1989, significant efforts have focused on improving the care of dialysis patients in the United States. Numerous organizations have developed clinical practice guidelines; however, few guidelines have received the broad support given to the National Kidney Foundation-Dialysis Outcomes Quality Initiative (DOQI). These guidelines, independently developed from an extensive review of the literature, include sections on dialysis adequacy, anemia treatment, and vascular access. To assess the impact of these guidelines on clinical practice, we evaluated data on hematocrits, recombinant human erythropoietin dosing, hemodialysis adequacy, and simple fistula and dialysis catheter utilization using Medicare dialysis provider claims and Medicare Part B physician services. Hematocrits have increased steadily, with the exception of the period when the Hematocrit Measurement Audit was in effect. After cancellation of the policy, hematocrits increased to the midpoint of the DOQI target range (34.4%). Although the level of dialysis therapy has stabilized, with the average urea reduction rate of 68% to 69.9% in 1997 to 1999 being slightly greater than the DOQI target of 65% or greater, geographic variability is apparent. Simple fistula placement rates increased by 45% during the pre-DOQI and post-DOQI period from 1994 to 1999. The use of temporary catheters decreased, whereas placement of permanent catheters has increased, which may reflect recommended practice guidelines. Although it appears that clinical practice guidelines have improved the clinical care of dialysis patients, considerable regional variations in care across the country should be given significant attention.
Rehabilitation of patients on dialysis encompasses vocational, physical, psychological, and social domains. Rehabilitation efforts in each of these areas require not only a team approach but also performance of specific roles and responsibilities by each member of that team. This National Kidney Foundation survey will show that nephrology professionals do not routinely associate their main professional activities with the rehabilitation of their patients and that all too frequently dialysis patients do not see rehabilitation as within their realm.
BACKGROUND/PURPOSE: Traumatic injuries cause substantial morbidity and mortality in children. Trauma registries are essential to assess and improve standards of trauma care. An interprovincial study of pediatric trauma between 6 centers across Canada who use identical software components was completed. METHODS: Data were collected from April 1, 1995 to December 31, 1998 for children aged 1 day to 17 years with an injury severity score of > or = 12. Cause of injury, injury time and day, gender, age, injury scores, length of hospital stay, and outcomes were compared. RESULTS: A total of 1,276 patients were included. Mean age was 10.3 +/- 5.6 years. Motor vehicle collisions were the most common mechanism of injury (56%). Boys were more often injured (66%; P < .05). Injuries occurred mainly between 1600 and 2400 hours (P < .0001). Mean hospital stay was 11.5 +/- 16.6 days. The longest stays in the hospital were among those who had an abdominal abbreviated injury score (AIS) of 1 (P < or = .03). Patients with similar injury severities remained twice as long in Winnipeg Children's Hospital (hospital 5), hospital 2, and hospital 6 as compared with patients in hospital 3 (P < .05). Differences existed in discharge placement between hospitals (P < .0001). CONCLUSIONS: This study was the first to compare pediatric patients in multiple Canadian centers using identical trauma registries. Variations in length of stay and discharge placements between hospitals were identified. Further analysis of data in the registries may clarify these differences and serve as a foundation for hospitals to improve the quality of patient care.
OBJECTIVES: To describe the importance of standardized nursing vocabularies as a foundation for quality in health care decision-making. DATA SOURCES: Literature, online sources, and committee documents. CONCLUSIONS: Several standardized vocabularies are recognized by the American Nurses Association Committee for Nursing Practice Information Infrastructure. Vendors also have integrated the vocabularies into their information systems. Future efforts include developing an international nursing reference terminology. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses face quality of care issues that impact decision-making at the point of care. To describe their practice, oncology nurses must strive to use nursing data that are standardized, documented, and made visible by inclusion in computer-based systems.